NUR 322 Case Study

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Transcript of NUR 322 Case Study

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Erica Weiser

Fall 2015

NUR 322 CASE

STUDY

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Reason for hospitaliation! r"pt"re#$e$%ranes& '(D

)atient *nfor$ation! *nitials! A+)+

A,e! 31 -.o

Se/! Fe$ale

Ethnicit-! WhiteC"rrent patient stat"s! pri$i,rai#a

ith tins thro",h *F

)AT*ENT DE4RA)6*CS

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*$$"niation stat"s! "p to #ate

7loo# t-pe an# Rh stat"s! 4 positie

Ne,atie for! 6*

Strep

6epatitis

No preio"s s"r,eries or in8"ries

Aller,ies! )enicillin& Clo$i#& 6-#roco#one

Chronic illnesses! #-s$enorrhea

e#ications! prenatal ita$in

)reio"s %irth histor-! 9 rst pre,nanc-

ED*CA' 6*ST4RY

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ran#parents

)arents

Si%lin,s! 3

FA*'Y 6*ST4RY

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Fa$il- $a:e;"p

E$plo-$ent

E#"cation

*ns"rance6i,h;ris:

%ehaiors

6o$eeniron$ent

School

Actiities

)SYC64S4C*A' 6*ST4RY

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)atient Stat"s

Sta%le

Free of #isease

'a%orin,

6olisticall- health-

N"rsin, Theor-

 <ean Watson Theor- of 6"$an

Carin,

)6YS*4'4*C STATUS

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Eri: Eri:son=s theor- of ps-chosocial#eelop$ent

eneratiit- s+ Self;A%sorption an#

Sta,nationi##le A,e

DEE'4)ENTA' STATUS

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6ei,ht! 5= 5>

Wei,ht! 20? l%s

)re;pre,nanc- ei,ht! 1@2 l%sAppearance! nor$al

N"tritional stat"s! a#e"ate

Co"nselin, an# e#"cation

R4WT6 AND NUTR*T*4NA' STATUS

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ital si,ns! B?+2o&B?& ??& 1& 121.

Chest! no $"r$"rs&WD'

'"n,s! clear %ilat& WD'

enitalia! Bc$& 100&2Sli,ht a$niotic an#

%loo#- #ischar,e7ac:.E/tre$ities!Epi#"ral in place

3 e#e$a %ilat on feet

)6YS*CA' ASSESSENT

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)atient=s al"es

6e$o,lo%in! B+5

6e$atocrit! 2+5

)latelets! 1@&000

W7C! 10&B00)otassi"$! 3+0

Nor$al al"es

 G11 ,.#'G33

150&000;00&000.$$3

5&000;10&000.$$3

3+5;5+0 $E.'

'A7 A'UES

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Oxytocin (Pitocin)

Fentanyl 

Methergine

)renatal ita$in

7a%- Aspirin

ED*CAT*4NS

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ANA'YS*S AND SUARY

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4"tco$es! )atient illH State acc"rate infor$ation re,ar#in, %irthin, process ithin 1

ho"r+

*#entif-& er%alie& an# #e$onstrate copin, %ehaiors that re#"cefear %- ti$e of #elier-+

*nterentions! N"rse illH  Teach patient rela/at ion techni"es incl"#in, #eep %reathin,&

,"i#e# i$a,er-& $"sic therap-+

Enco"ra,e h"s%an# an# fa$il- to :eep patient co$pan- #"rin,la%or process+

 Teach %ene9ts of an epi#"ral to re#"ce pain an# help ith an/iet-

r.t pain+ Esta%lish a list copin, $echanis$s that hae or:e# in the past

for the patient+

Eal"ations! oal $et+ )atient state# acc"rate %irthin, plan ith re#"ce#

an/iet- ithin 1 ho"r+ Discontin"e ,oal+

oal $et+ )atient i#enti9e# #eep %reathin, an# ,"i#e# i$a,er- ass"ccessf"l rela/ation techni "es+ Contin"e oal "ntil after

FEAR R.T 'A74R AND DE'*ERY AE7 RE)4RTS4F NER4USNESS& F*RST )RENANCY AND7*RT6& 6A*N TW*NS& *NCREASED 6EART

RATE

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4"tco$es! )atient illH *#entif- actions that can %e ta:en to ens"re a#e"ate sleep ti$e

%- en# of shift+

Aa:en refreshe# as soon as a#e"ate ti$e is spent s leepin, %-#ischar,e+

*nterentions! N"rse illH 4%tain a sleep histor-! ho $"ch& "se of sleep ai#s& or: an#

fa$il- responsi%ilities that ill inI"ence sleep ha%its+

Enco"ra,e nappin, as a a- to co$pensate for sleep #epriationat ni,ht+

E#"cate patient on %ene9ts of hain, epi#"ral $e#ication to

pro$ote co$fort an# sleep+ *f patient %eco$es itch- ith$e#ication& 7ena#r-l a#$inistration can also help in#"cesleepiness+

Eal"ations! oal $et+ )atient i#enti9e# epi#"ral an# #ar:ene# roo$ itho"t

eniron$ental sti$"li as factors to pro$ote sleep+ Discontin"e

,oal+ oal not $et! )atient #i# not sleep for e/ten#e# perio# of ti$e to

S'EE) DE)R*AT*4N R.T UNC4F4RTA7'E)RENANCY STATE AE7 DAYT*E DR4WS*NESS&

FAT*UE& REST'ESSNESS& STATES S6E CANN4T F*ND AC4F4RTA7'E )4S*T*4N

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4"tco$es! )atient illH De$onstrate loin, relationship ith chil#ren at ti$e of #elier-+

)roi#e a safe& n"rt"rin, eniron$ent for %a%ies %- #ischar,e+

*nterentions! N"rse illH Use fa$il-;centere# care an# role $o#elin, for holistic care of the

fa$il-+

Assess parents= feelin,s hen #ealin, ith %a%ies %ein, a#$itte#to the N*CU+

E#"cate patient on :an,aroo care for infants! :eepin, infants in an"pri,ht position in s:in;to;s:in contact+

)roi#e opport"nit- for the patents to assist in the ne%orn=s 9rst%athin, an# treat$ents+

Eal"ations! oal $et+ )atient #e$onstrate# loin, relationship an#

attach$ent to %a%ies at #elier-+ Discontin"e ,oal+

oal $et+ )atient an# h"s%an# proi#e# safe& n"rt"rin,eniron$ent for %a%ies+ Contin"e thro",h #ischar,e+

READ*NESS F4R EN6ANCED )ARENT*N R.T 7*RT6 4F TW*NS AE7 EJ)RESSES W*''*NNESS T4 EN6ANCE

)ARENT*N& E*DENCE 4F ATTAC6ENT& STATESREAD*NESS 4F 7EC4*N F*RST;T*E )ARENTS

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Ac:le-& 7+ < + ( 'a#i,& + 7+ K201L+ N"rsin, #ia,nosis han# %oo:! Anei#ence;%ase# ,"i# e to plannin, care K10th e#+L+ St+ 'o"is& 4! os%-Elseier+

'a#ei,& )+A+& 'on#on& +'+& ( Dai# son& +R+ K2013L+ Contemporarymaternal-newborn nursing care.   K? t h  e#+L+ Upper Sa##le Rier& N<! )earsonE#"cation+

)a,ana& M+ D+& ( )a,ana& T+ <+ K2011L+ Mosby’s diagnost ic and laboratorytest reference.  K10th e#+L+ )hi la#elphia& )A! FA Dais Co$pan-+

)otter& )+ A+& ( )err-& A+ + K2013 L+ Fundamentals of nursing   K13th e#+L+)hila#elphia& )A! F+ A+ Dais Co$pan-+

)renatal $"ltiita$ins $e#ical facts fro$ Dr",s+co$+ K201& 4cto%er 2@L+Retriee# Noe$%er 5& 2015& fro$ http!..+#r",s+co$.$t$.prenatal;$"ltiita$ins+ht$l

aleran#& A+ 6+& ( Sanos:i& C+ A+ K2013L+ Dais=s #r", , "i#e for n"r sesK13th e#+L+ )hila#elphia& )A! FA Dais Co$pan-+

Wa,ner& A+ K2010L+ Core Concepts of <ean Watson=s Theor- o f 6"$anCarin,.Carin, S cience+ Retriee# Noe$%er & 2015& fro$http!..atsoncarin,science+or,.9 les.Cohort .atsons;theor-;of;h"$an;carin,;core;concepts;an#;eol"tion;to;caritas;processes;han#o"t+p#f +

RES4URCES

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http!..+e#o$i+or,.,eno,ra$.

https!..cheert#+or#press+co$.201.03.

http!..h"$an,enetics+"chc+e#".$otherO%a%- .

http!..+n"rsin,e/plorer+co$.careers.perinatal;

n"rsehttp!..%lo,s+la-ers+co$.2012.10.%irth;$other;as;$e

re;s"rro,ate;sa-s;,a-;father.

)64T4 CRED*TS